Mental Health Parity

Interesting article in the New York Times this weekend. Click here to read it.  It is fascinating to me that there are still people in the world who value physical illness differently than mental illness.  Why?  We can't prevent a heart attack by "force of will".  Why do we insist that, if the brain goes haywire, it is fixable with just a bit more attention to detail.  Why is a feeling of soreness in the throat more valid than the a feeling of hopelessness?  What can we be exhausted from the flu but not post-partum depression.  I know that those of you in practice know what I am talking about.  

My favorite line is "anything that would not turn up in an autopsy, as in depression or agoraphobia, cannot be equated with physical illness".  Much of what we do won't show up on an autopsy!  Heart arrythymias, seizures, even a potassium chloride overdose won't show up on autopsy.   These false dichotomies have got to go.

Crisis Teams: When does a crisis involve boots on the ground?

Families are frustrated by long waits in the Psychiatric Emergency Rooms that are happening all over the Commonwealth, and the remedy proposed that we move those services out to the home.  One would hope that, in the context of Intense Care Coordination and consistent screening programs, we would have fewer families in crisis requiring that level of intervention. Crisis intervention is a terrible way to manage mental illness.  Of course, it will be difficult to maintain a level of expertise in this area as it becomes less common.

(1) What suggestions do you have for structuring the Mobile Crisis Intervention service across the Commonwealth?

The first thing to realize is that a 45 minute response time is not possible in many parts of the Commonwealth unless Masshealth is going to pay for helicopters. In South Worcester County, it takes that long to get to Brimfield or Ware. The standards for “Crisis intervention” need to be rewritten to reflect that reality. Most crises happen in the context of poorly coordinated care for children previously identified as having difficulty. That said, crisis management requires three things:
1) “De-escalation”: Like Henry Goldblum on the old “Hill St. Blues” TV show, we need people among the “first responders” (police, EMT and fire fighters) who are able to “talk down” the person involved in the “immediately” dangerous behavior. That person should be local, and able to contact the Mobile Crisis Team for the region in which they work.
2) Transporation protocols: Universal protocols for transport to Emergency Mental Health Services, covering issues such as the use of physical and chemical restraint, ambulances vs. police vehicles and notification of family.
3) Mobile Crisis Protocols: These should include discretionary powers on behalf of the Team to decide the level of intervention needed at this time.
4) Emergency Planning: Calling the team or designation as a member of the SED class should involve the development of an individualized emergency plan for the child and family.

(2) What is the appropriate number and qualifications of staff for a Mobile Crisis Intervention team? 

They probably need to be similar to the requirement for Emergency Mental Health work in general.
(3)What suggestions do you have regarding coordination of Mobile Crisis Intervention with other services, including the other Initiative Services discussed in this RFI?

From Chris Stille:  

As discussed in the response to 2.1.3, 2.3.B(1) and 2.3.B(4), there is a need for crisis plans and crisis teams to engage in communication and coordination with the child's ongoing medical (including primary care) and mental health service providers, as well as with their school. The goal of this process would be to help children and families transition smoothly between levels of care (both up and down the urgency/intensiveness ladder). We feel this would be facilitated by proactive designation of a person or small group of people as each child's crisis team, ideally determined BEFORE a crisis occurs. This would further enable well-planned, well-coordinated care. 

Amen.

Collaboration: The friend of Rosie D.

The meat of the matter- how do we collaborate? Most of the children in the class of SED were buffeted about the system like the kid in "Officer Krupke" from "West Side Story".  How do we break through the silos? How do we make it all come together?  

(1) What structure(s) would best support collaborative practice between public agencies and among private providers? What are the advantages and disadvantages of addressing coordination issues among public agencies and private provider agencies in the same forum? Should there be separate settings for these discussions? How can MassHealth best ensure integration of all aspects of delivery of care and mutual accountability for outcomes?

This is a tricky question, and key to the outcomes of this remedy.  The structure that will best support collaborative practice is the one that best allows integration of the needs and strengths of the family with abilities and resources of the agencies involved.  The ICC will need to work with the family in the process of developing the service plan to identify the structure that will support the family best,  and assure that the agencies and providers are able to utilize that format.  At some level, it is important to put faces to words, but much of the work can likely be accomplished through virtual formats.  MassHealth needs to ensure that there is regular communication within the treatment team, to avoid a crisis-focused approach.

MassHealth should provide for a variety of formats to accomodate the different types of teams with which we are dealing:

1)  Face-to-face:  Catalog and contact information for facilities willing to host multidisciplinary team meetings, travel reimbursement, access to on-line scheduling service.

2)  Phone meeting:  Reimbursement to support time and cost of conference calls.

3)  Virtual meetings:  Secure "chat rooms" and "bulletin boards" for sharing confidential informantion.

4)  Shared single care plan:  On-line care plan accessible to all parties (so that each can see what the other is doing).

It seems likely that an initial "face-to-face" meeting followed by routine conference calls will likely be the preferred format for interaction, but, ultimately, the adequacy of the interaction should be judged by the needs of the family and the outcomes of care.

(2) What are your suggestions for ensuring collaborative practice among different individual providers or provider agencies serving the same child/family?

The current system of reimbursement does not encourage collaborative behavior- the various components of the system are rewarded for each piece of work done, not for work avoided through collaboration. Reimbursement needs to reflect the quality of the interaction as well as the quantity of the services provided. I would suggest considering the families assessment of the degree of collaboration as a multiplier to reward collaborative behavior.

(3) What are your suggestions for SOC Committee membership and meeting format to balance the value of having family and youth represented on the Committee with the need to protect the privacy of children and families involved in ICC?

In a truly family-centered paradigm, it is difficult to imagine “one size fitting all”; the SOC membership needs to reflect the array of services and service providers that are working with a given family. This is a deeply personal negations between the intensive care coordinator and the family. Some portions are non-negotiable (ie. DSS must be involved with clients engaged in the system, whether the family wants it or not) and it will be difficult when the family has had conflict with one of the agencies essential to service delivery (ie if the family has long-standing disputes with the Special Education Department, they may not want to invite them to be on the team even though they are essential to the process). I suspect that the most difficult cases will be those in which custody is in dispute. The care coordinator needs to be given discretion and training to negotiate and sometime mandate who will be on the team.

(4) What are the advantages and disadvantages of combining discussions of policy and general coordination with discussions of specific service coordination problems, which would require disclosing personal information? Should there be separate settings for these discussions?

Generally, these discussions take place at different levels within agencies. While it is important for fieldwork to inform policy, field workers are usually not in a position to set policy, except in some of the smaller agencies. Still, in order to relate policy to reality, it is important to have discussions in which those that set policy hear how the policy plays out in specific cases. In medical culture, this occurs at the “M and M” conference, in which the details of a specific case are discussed (with identifiers removcd) in a secure and non-discoverable environment (papers burned afterwards). This may be a model that would be useful to this process of multi-agency collaboration, and may require legislative protection similar to that afforded medical staff in hospitals.

(5) What suggestions do you have or lessons have you learned for facilitating partnerships with school districts?

In general, all agencies have a specific mission, and they will collaborate with “outsiders” based on the abilitiy of the outsider to help them to achieve that mission. With schools, it is about improving educational outcome, so as an “outsider”, I have had to think about how my expertise can help a school system accomplish its mission (and how they can help me to accomplish mine). This is a nuanced take on the prime question “How can I help this child”. Several other hints:
1) Show up. Schools respond to people to respond to them through team meetings.
2) Match objectives: Completing homework is a great measurable behavioral objective that meets my needs as a prescriber and their needs as educators.
3) Share information: A five minute phone discussion can cut through weeks of written messages.
4) Understand their schedule: Schools are open on school days and are generally closed by 3 PM. Call in the morning.
(6) What suggestions do you have or lessons have you learned for facilitating partnerships with juvenile courts? Probation?

Actually, substitute courts and probabtion for schools in the above paragraph, and you have a reasonable set of advice.

(7) What suggestions do you have or lessons have you learned for facilitating partnerships with broader system partners?

Ditto.

(8) Do you have any other comments or suggestions on these subjects?

All of this collaboration takes time, and we need to reimburse individuals and agencies for taking the time to collaborate.

Guest Spot: Disabilities Sensitivity is a Cultural Competence

I am writing in this blog to advocate one component of cultural competence. I am aware that there are some organizations in the Boston area who are hired to train mental health professionals and social service workers on multicultural sensitivity training. I attended one such training last year and though the information and presentation was excellent by "Families First," it did not provide any information on how to work with individuals with disabilities.

Mass Health can implement Disability sensitivity as one component of Cultural Competence. By coincidence, Blue Cross/Blue Shield of Massachusetts interviewed me two weeks ago about the need to include the above topic as a cultural competence for mental health professionals. It is also important that medical professionals also receive the same training in this area as well. Currently, Tufts University and I believe UMASS has patient-doctor trainings in which "hired" patients train doctors on how to interact with them and to understand their symptoms. I heard positive feedback from persons with disabilities who participate as patients in this training.

Mass Health can recommend that clinics/facilities that staff receive trainings similar to the Patient/Doctor model that is currently being used. The question is how to pay staff to attend such trainings. That is always the tricky part of the equation. For mental health professionals, CEUs can be awarded to going a training during a staff meeting or a special meeting time. But again, mental health clinicians do not get paid for mandated staff meetings. This issue of payment or compensation has to worked between Mass Health and the provider.


Why do medical and mental health professionals need to learn to be more culturally competent in this area?

1) The is a new population of veterans coming home from Iraq and Afganhistan who are newly disabled and will need both medical and mental health services. The current health insurance benefit for vets is not adequate to cover all their healthcare needs.
2) More and more persons with disabilities across the board are living in the community and not necessarily in institutions. Governor Patrick's plan for Long Term call for more funding to be used for community based services for individuals with psychiatric disabilities; developmental disabilities with physical disabilities to live in the community across the commonwealth.
3) Professionally and personally speaking, I heard numerous complaints from consumers and advocates with disabilities vent their frustrations on how their medical or mental health professional treated them for their symptoms. An example is when an individual goes to a health facility with a personal care attendant, the medical professional tends to talk to the PCA and not to the client. Another example is when a colleague of mine who is a wheelchair user told me how her mental health clinician told her to go fight her "revolution" during the last session. The revolution is about the barriers in the environment that prevent persons with disabilities from enjoying the same freedoms as their able-bodied counterparts. We both wondered if she would tell a person from a multicultural background the same information. I think not..

Robbin Miller
Advocate/Counselor

The Culture Question: What is the culture of the Commonwealth?

I have been getting feedback from many of you in the Network.   Thank you.  I have elected to not edit my draft responses on the blog, but to integrate your comments into the "final document", which I will try to post as a .pdf next week.  We will see how this goes.

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These are hard questions.

(1) CSAs will serve relatively large areas with diverse populations. It may be difficult for one organization to have the cultural expertise to effectively serve such a broad range of needs. What strategies would you suggest to ensure that culturally competent care is available for all MassHealth children and families who need behavioral health services in a given Service Area?
This is an incredibly challenging issue, as we are facing an array of patients from a variety of backgrounds like we have never seen before.  A few ideas:

1)  Development of a statewide registry of resources (people) and services provided throughout the Commonwealth. This would allow interagency referral and facilitate the ability of people to address needs when there are no local resources.  

2)  Adequately funding the use of "off-site" interpreters for folks with language needs that cannot be met locally.  This requires providers to have the proper equipment (ie.  speakphones or videoconferencing capability in the exam rooms)

3)  Developing a "fast track" to recruit and credential therapists who were born and raised in other cultures.  They may help to provide some level of service.

4) Support agencies that recognize their limitations and seek outside support, rather than penalize them for not having the right services on-site.

(2) What suggestions do you have for strategies to reduce any health care disparities in the area of behavioral health?
First and foremost, we need to track the screening and referrals of folks with respect to race and ethnicity, so that we can actually get a handle on what the disparities are.  It is sometimes challenging to assign patients to a certain race and ethnicity, and one certainly difficult to deal with a problem until you have defined it.  We should also engage in a discussion (or perhaps focus groups) to identify barriers perceived by different sub-populations and respond to them.  Finally, we need to push the definition of patient focused care to incorporate the families health belief system into the treatment plan.  I defer to the group regarding other ideas.

(3) Are there models of culturally competent care you think MassHealth should consider?

Yes.  One is the  the "Latino Mental Health Project, which  partners the Massachusetts Department of Mental Health with community health centers and local health care providers to identify barriers preventing Latinos from seeking mental health care. With a grant from the American Psychiatric Foundation, CMAHEC created “Hablemos en Familia,” a series of workshops educating Latino community members to recognize, cope with and seek treatment. The federal Office of Minority Health recognized the program and selected CMAHEC from 500 entries to present at its national leadership summit.".  

Another is the HOPE Coalition (Healthy Options for Prevention and Education) is a youth-adult partnership coalition created to reduce youth violence, substance use and promote adolescent mental health in the City of Worcester. (Laurie Ross, Coordinator Phone: (508) 793-7642 , Email: LRoss@clarku.edu).  Both of these build on partnerships with community-based organizations to make it all work.

CSAs: What are they good for?

Now we are getting to the heart of the Rosie D remedy: the CSA. According to the guidance:
"... the CSA will provide ICC to MassHealth-enrolled children and youth in the Service Area. ICC will provide the Wraparound Care Planning model of care coordination. Wraparound Care Planning is based on an ecological understanding of the child and the child’s functioning. The process assesses, engages, and works with all aspects of the child’s “ecology”: the child’s physical and mental health, family, extended family, peers, school, recreation, and communities to which s/he belongs. To effectively partner with families to engage this full breadth of the child’s world, the CSA needs to have and continually nurture relationships throughout its community, including with primary care providers, hospitals, schools, community agencies, other providers, recreational programs, child care resources, housing and food programs, residential and shelter providers.
The CSA also needs to be able to train, supervise and administratively support the clinical and paraprofessional staff who will be working with children and families in ICC. The Wraparound Care Planning model is promising in its ability to develop highly individualized, clinically sophisticated, multi-dimensional care plans. However, for the very same reasons, it is a challenging model to learn, to master and to sustain."

These CSAs sound like a cross between Annie Sullivan,  Saul Alinsky and Jane Addams.  Can this really be done?  Anyway, the RFI looks for our input.
(1) Do you have any comments or suggestions on the proposed CSA qualifications?

My first comment is one of wonder;  the bar is set (appropriately) quite high for this program, and it is not clear to me who will achieve that standard.  I am concerned about that the need to provide services from birth to 21 will restrict the ability of some agencies to apply, as the needs of families vary so much over that time span.  I am also concerned about having in place a model of Wraparound Services.  I suspect that, in many parts of the state, these CSAs will be "start-ups" because noone is doing Wraparound at present. 

(2) How do you suggest addressing potential conflicts of interest for ICC providers who self-refer?  

Good point.  It needs to be addressed openly.  You will need to demonstrate a firewall between the "care-coordination" side of things and the service delivery side.  

More questions. Ever more questions.

More questions from the RFI:

(1) How should CSAs ensure that Care Planning Teams have access to needed medical and psychiatric expertise? 

The medical and psychiatric needs of the members of the Rosie D. class are likely to vary from case to case;  most children with Serious Emotional Disturbance will need a primary care provider and some sort of specialist in diagnostic evaluation and treatment (child psychiatrist, child neurologist or developmental/behavioral pediatrician).   However, I would not separate them from the rest of the team-  the physicians need to be tightly integrated with the team, not just consultants who intermittently offer opinions.  One of the problems with the current model of "medication consultation" is that the psychiatrist is not afforded time to understand the patient and family before being forced to offer an opinion.  Medical and psychiatrists serve several roles on the team:

1)  Diagnostic:  Sorting out these symptoms requires a physician who understands child development, the wide range of normal, and the various diagnoses we need to consider.  They also are key to understanding the role of social factors and physical illness in the process.

2)  Therapeutic:  Physicians (generalist and specialist) often have a better idea of what is possible in the mileau in which the patient lives.  They are also able to prescribe medications, although one must be careful of over-medicating or "off-label" use of medications.

3)  Monitoring:  Efficacy and side -effects.  This approach has been well addressed in the "chronic disease model mentioned earlier.

4)  Advocacy:  A doctor can be of great assistance to the family in navigating the system.

A few ideas, which depend on the model of care:

1)  If the CSAs serve mostly to link families and services through care coordination, then is incumbent on the CSAs to make connections with local resources.  In areas that are currently devoid of services, the CSA may need to be the conduit for care.

2)  In areas with little access to needed services, the MCPAP program can serve to support primary care physicians who often serve the role that would be better served by child psychiatrists.

3)  CSAs in areas with few resources may wish to pursue telepsychiatry as a means of access for child psychiatry.

4)  Supporting the expansion of the profession:  All three of the subspecialists mentioned above are not well compensated for caring for these complex children.  That needs to be addressed.

(2) Which of the needs listed above are likely to occur most often, or require most extensive use of medical or psychiatric expertise?

It seems to be that the hardest thing in all of this is the diagnostic formulation;  in the ideal world that takes the most time, and requires clear thinking and a comprehensive overview of what is going on.  Over and over again, we hear from families that "no one has truly evaluated my child", while the child is on a regime of 4 or 5 psychotropic medications, each one treating the side effects of the medication prescribed previously.  The diagnosis in children has to be developmental and fluid, but as important is that the diagnostic process allow that family to be heard.

After that is the sorting of therapeutic options:  medications (mostly prescribed off-label, with limited evidence), various forms of therapy, educational planning.  In the new model, there will need to be an integration of things with the wraparound components.

(3) Based on your program experience and knowledge of the clinical workforce issues in your region of Massachusetts, what staffing arrangements make most sense for CSAs in providing medical and psychiatric expertise? Which disciplines (e.g., child psychiatrist, child-trained APRN, child-trained RN, behavioral pediatrician, or other medical professionals) can be most useful in which roles?

In Central Massachusetts, we have a strong group of primary care pediatricians who are interested and willing to work with children with SED, but who are beginning to feel the time pressure of practice-  i.e. how do I make time in the day to be part of a multi-disciplinary team.  We have a number of agencies working with children with mental health issues in Worcester and a robust private practice community in the Worcester city;  psychiatric resources outside of the city are almost non-existent, especially in the South Central and Blackstone Valley regions.  We have no access to behavioral pediatrics for children under 5 and one behavioral pediatrician for children over 5 IN THE ENTIRE COUNTY!  Child psychiatry is a bit better- there are limited services for children in Worcester through 5 or 6 or so FTE child psychiatrists in the City, and 1.5 FTE in South Worcester County.  Child neurology is similarly limited.  The MCPAP program is robust, but is asked to see complex children frequently (given the conditions mentioned about)

(4) What suggestions/lessons learned do you have regarding collaboration with community medical professionals, including child psychiatrists?

1)  Enable multiple modes of communication (beeper, phone, e-mail)

2)  Allow short term consultation

3)  Recognize the limits of the model.

The MCPAP has shown that the most important component of providing collaborative care is the development of an on-going relationship between the PCPs and the child psychiatrist;  both professions can provide better care from the ability to converse in person and via e-mail.  The program has allowed us to "leverage" existing resources in the County, which has been useful for both the SED kids and the kids who are "one notch below" SED.  THe relationship must include a recognition by the consultant that, in most cases, when the PCP asks the consultant to meet with the family in person, that is a serious request that must be honored.  Also, there are some kids where the MCPAP relationship is not enough-  the system should have flexibility to allow psychiatry to move from a consultative to a therapeutic role, and back again.

(5) What are pros and cons of the CSA providing ongoing psychopharmacology services for enrolled children?

Given the overall shortage of providers for psychopharm services in the Commonwealth, it is difficult to think of any downside to the CSA providing services to clients. Except this: perhaps our shortage of providers is the only thing preventing a higher degree of overmedication than what we see already. The evidence base for much of our management of children with mental illness is small, and needs to grow. I would submit that any psychopharm services provided through the newly established CSA include a strong evaluation components, recognizing the quasi-experimental nature of much of this and serving as an entry point to a multitude of clinical trials designed to answer the question- is this medication in this situation worth the risk? The downside of providing more psychopharmacology is that the market will drive us to overmedicate, if we let it do so.

(6) Is there a role for regional or statewide collaboration in ensuring access to medical and psychiatric expertise for ICC?

Yes. I think that is inherent in the responses lists above.